Among new nursing assistants, perhaps no other topic provokes as much fear as does dealing with death and dying. As in most medical careers, for nursing assistants, death is one of the realities of caring for the ill and/or elderly. I remember discussing the dying process and even post-mortem care in my CNA training classes, and I was horrified at the thought of even being near a dying person--especially if that person happened to be someone I had cared for. I wasn't sure how I'd handle it, the first time I was confronted with it. I remembered hoping that I would never become cold and callous, I hoped that caring for a dying patient never became 'routine'.
Death and dying means different things to different people. Some people, depending on spiritual beliefs, may view and face death with an amazing calmness and peace. Others may fear death and fight it to the finish. Some people may prefer to be alone in their final hours, while others are terrified to be alone and may wish to have someone with them at all times.
Comfort is key, in caring for a terminally ill patient who is nearing the end. Try to maintain a quiet atmosphere, and be respectful. If you are caring for the person with another aide, don't spend a lot of time talking between yourselves, and above all, DO NOT SPEAK ABOUT THE PATIENT within earshot--even if you are convinced the person cannot hear you and doesn't know what's going on in the room. It is a known fact that people who have come out of comas report being able to hear conversations going on around them. I have gone into a room to care for a dying patient with another CNA and the temptation is there to wonder out loud 'how much longer?' Remember to be respectful. Put yourself if the patient's place...because someday it will be you. How would you want to be cared for?
Keep the patient as comfortable as possible. One basic care is mouth care. Often, the mouth will become very dry. If the patient is NPO (nothing by mouth) check with the nurse before providing mouth care. Usually, all that is needed is a wet swab (wrung out as much as possible for NPO patients) using water, diluted mouthwash or a mixture recommended by the nurse. Keep the lips lubricated with Vaseline or a similar product, to prevent cracking.
If the patient is postioned in bed on their side, be sure to place either a pillow or a neatly folded thin blanket between their knees, to ensure comfort. It is also a good idea to place a support behind the patient's back, to keep them comfortably in position. Remember--even if the patient is unresponsive, ALWAYS be sure their call light is within reach.
Pay attention to the temperature in the room! Does the patient feel hot and sweaty? Perhaps just a sheet will be enough covering. If the patient's arms and legs start to feel cold, this is often a sign that the body is starting to fail. The cool extremities are a result of the body trying to draw any available heat into it's core to maintain functioning. Eventually, the body will fail further and the skin will become mottled. The mottling of the skin is another sign that death is imminent.
If the patient is bedridden, be sure to reposition them at least every two hours. If the patient is placed on their back, be sure the head of the bed is elevated at least 45 degrees, to make breathing easier. As death draws near, respirations become more labored and something called 'Cheyne-Stokes' begin, which is shallow mouth breathing with periods of apnea. As the body's respiratory and cardiovascular systems begin to fail, fluid accumulates in the lungs, resulting in a rattling sound often referred to as the "death rattle" among health care workers. When this begins, it's a sign that death will usually occur within 24-48 hours.
The signs of impending death include:
*Loss of muscle tone: There may be urinary or fecal incontinence and decreased GI activity. The patient may experience nausea due to abdominal distension. The gag reflex diminishes or is absent and the jaw may sag due to relaxed muscles.
*Slowing of circulation: The patient may experience lowered sensation and decreased sensitivity to pain and touch. The skin on the extremities becomes cold and may appear mottled or cyanotic. (blue-tinged). The pulse is weak and the blood pressure drops.
*Changes in respirations: Rapid and shallow, irregular. Mouth breathing, Cheyne-Stokes. Difficulty swallowing.
*Sensory Impairment: Blurred vision.....all senses dulled.
Be sure to report any changes in the patient's condition to the nurse, who will often provide comfort measures that nursing assistants are unable to provide, such as suctioning excess respiratory fluids to ease breathing, and providing pain medication to ensure comfort.
Keep handling to a minimum. Often, the patient will be in pain or be experiencing discomfort. Rolling and turning the patient in bed will often add to this discomfort. Sometimes it makes it easier if there are 2 nursing assistants performing care on the resident together.
If the patient loved music, it may be comforting to have a radio playing softly in their room. If they loved poetry, read them a poem or two. If they were deeply spiritual, reading to them from the Bible or another book of meaning to them may provide incredible comfort to them. Sometimes, just being there, holding their hand and speaking comforting words is enough.
If you are frightened to provide care to a dying patient, ask to have another nursing assistant in the room with you. New CNA's tend to be very uncomfortable when faced with failing patients. Veteran CNA's--remember what it was like when you first started out--and help the new CNA's!
I have been caring for patients since 1993 and I have heard it said about dealing with losing patients, "You'll get used to it". I believe this statement only applies to getting used to dealing with the signs and symptoms of impending death--not the actual feelings and emotions that go along with losing the ones we care for. In the beginning, new nursing assistants fear caring for a dying patient because they don't know what to expect. After the mystery is gone and the CNA has experienced death a few times, all that is left is the pain of losing the ones we've come to know and care for. Sometimes it can feel like losing a family member.
If you are especially close to a patient, you may find it difficult to provide end of life care to them. It's ok to explain this to the nurse in charge. If it will be too emotionally difficult for you to deal with, perhaps you can be relieved by another CNA. On the other hand, I have also felt as though I really wanted to be the one giving care to patients I was especially attatched to. There is something extremely gratifying in giving excellent, quality care to someone you love during their last days on earth. We will all face death someday, and nursing assistants are in a position to make the transition a comfortable one for people.
Changes in body after death:
Rigor Mortis: body becomes stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and supple.
Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily.
Livor Mortis: Dependant parts of body become discolored. The patient will likely be laying on their back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down.
Hospice Links/Understanding Death
